Improving Research and Clinical Care, Bladder Cancer in Women - Jean Hoffman-Censits
May 10, 2020
Medical Oncologist and co-leader of the Women's Bladder Cancer Program at John Hopkins, Jean Hoffman-Censits joins Alicia Morgans to speak about bladder cancer in women and the initiatives and importance of the Women's Bladder Cancer Program. In many cases, there are significant delays in diagnosing bladder cancer in women. Dr. Hoffman-Censits discusses the continuous narrative of the delay in diagnosis and the isolation that women feel with the diagnosis of this disease.
Biographies:
Jean Hoffman-Censits, MD, is a genitourinary medical oncologist at the Greenberg Bladder Cancer Institute and the Co-Director, Women’s Bladder Cancer Program at Sidney Kimmel Cancer Center at Johns Hopkins. Her clinical and research interest is in the treatment and development of novel therapies for cancers of the bladder, ureter and renal pelvis. She attended Jefferson Medical College, Medical School and spent her residency and fellowship at Thomas Jefferson University Hospital and the Fox Chase Cancer Center in Philadelphia, PA, respectively. Dr. Hoffman-Censits is board-certified to practice Internal Medicine and Medical Oncology and administers chemotherapy and cystoscopy to patients with a range of urogenital cancers. Her extensive publications cover a range of genitourinary cancer topics, including “Identification of Distinct Basal and Luminal Subtypes of Muscle-Invasive Bladder Cancer with Different Sensitivities to Frontline Chemotherapy“.
Alicia Morgans, MD, MPH Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.
Biographies:
Jean Hoffman-Censits, MD, is a genitourinary medical oncologist at the Greenberg Bladder Cancer Institute and the Co-Director, Women’s Bladder Cancer Program at Sidney Kimmel Cancer Center at Johns Hopkins. Her clinical and research interest is in the treatment and development of novel therapies for cancers of the bladder, ureter and renal pelvis. She attended Jefferson Medical College, Medical School and spent her residency and fellowship at Thomas Jefferson University Hospital and the Fox Chase Cancer Center in Philadelphia, PA, respectively. Dr. Hoffman-Censits is board-certified to practice Internal Medicine and Medical Oncology and administers chemotherapy and cystoscopy to patients with a range of urogenital cancers. Her extensive publications cover a range of genitourinary cancer topics, including “Identification of Distinct Basal and Luminal Subtypes of Muscle-Invasive Bladder Cancer with Different Sensitivities to Frontline Chemotherapy“.
Alicia Morgans, MD, MPH Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.
Read the Full Video Transcript
Alicia Morgans: Hi, I'm excited to have here with me today, doctor Jean Hoffman-Censits, who is a medical oncologist at Johns Hopkins and the co-leader of the Women's Bladder Cancer Program there. Thank you so much for talking with me today.
Jean Hoffman-Censits: Well, thanks for having me.
Alicia Morgans: Of course.
Jean Hoffman-Censits: Yeah.
Alicia Morgans: So I wanted to speak with you about the Women's Bladder Cancer Program and some of the initiatives and actually some of the data that you've gathered in your research around women and bladder cancer. But can you tell me a little bit about why it's so important for you to have started a Women's Bladder Cancer Program at Hopkins?
Jean Hoffman-Censits: Sure. I think for a couple of different reasons, and we at Hopkins are passionate about this. I know this is a research and clinical interest of yours as well. When our female patients come to us, they often come to us with a very different narrative than men with bladder cancer.
Men and women both have the same presenting symptom, which is blood in their urine that is often the first sign that there's something wrong that gets them to a doctor's attention. Most men will go either straight to a urologist or maybe to a PCP and then urologist, but a lot of women take a different route and maybe they're voicing their concerns to the primary care physician, but more often than not they are treated for urinary tract infections, sent to GYN, even GI and have other procedures before ultimately seeing a urologist for a urologic complaint, blood in the urine.
In part potentially because of that, women present at a later stage with their bladder cancer, oftentimes have a worse outcome of their bladder cancer. Whether or not it's all this upfront management that's somewhat different or is it really underlying biology or combination of both, I think we're all really trying to understand that. So that's one facet that remains very fascinating, I think an unmet need for our patients is really working on that and understanding.
But the second is that process and that experience of that medical journey that a lot of women feel can be very isolating from the time that they have blood in their urine, the circuitous route to get to a urologist and then getting into that urologist office, they're often sitting in a room filled with other fellow patients who are most likely male. And then seeing a provider that's also most likely male as well. So a lot of women will come back to us in different forums and really be looking for other women who are sharing a similar experience as they're going through this journey with having a cancer diagnosis.
So I think just identifying that as a problem and an experience that we want to improve upon is important. And I think that's not only happening at Hopkins, but other centers across the country are starting to think of this as an important problem.
Alicia Morgans: Absolutely. And I think we've talked about this before, but there are some supportive care needs that women don't necessarily ask for, but really feel that they need, especially if they end up having a surgery for muscle invasive disease, like a cystectomy that leaves them with an ostomy for example. There are lots of psychological needs, some sexual needs that they need to discuss and to work through that may not always necessarily be addressed. And I love that your program really tries to address all these supportive needs around the cancer therapy itself as well.
Jean Hoffman-Censits: Yeah, absolutely. I think a lot of cancer centers have general support groups or patients with a cancer diagnosis kind of get together and have discussions and those of us that have larger bladder cancer programs, we'll have bladder-specific support groups where patients can learn from each other and at different phases along the journey, I think really come together and get the kind of knowledge and support and needs met that we really cannot do in a clinical encounter.
But one of the things that we were finding is that women felt very reluctant to speak up about really sensitive topics that only we are kind of used to talking to each other about in small groups. And so we decided not to exclude men but at the same time give women the opportunity to just talk to other women together about what does this feel like and interacting with your partner after having this procedure done or even thinking about dating after having this procedure done.
So every day we learn, I think so much from our patients and having the privilege of being a part of that support group, I think we really learn what it is that they really need and then how we as providers and people who think about these programs can make lives better for our patients kind of moving forward.
Alicia Morgans: So I know in addition to these supportive needs that you're, really addressing in your local institution, you've done some great work looking at clinical trials that have actually been completed and have thought about subgroups within the trials, thinking about trial outcomes by gender. So are there different outcomes for men versus women in completed clinical trials, where the data is accessible and you had a wonderful ESMO poster where you really kind of dug into this and I'd love to hear about that work.
Jean Hoffman-Censits: Sure. So you know, because there's never a 50/50 split in our clinical trials, there's the patients who come into our office and the incidence of bladder cancers, it's much more common in men than women. And so when you look across our large phase and you know Late-line metastatic trials, there's always 70% men and 30% women. And I think that's something that we have to kind of think about as an endpoint moving forward is thinking about potentially designing trials with a 50/50 split, at least as a secondary endpoint and kind of thinking about.
But until that day happens, we have large data sets where we can take a retrospective look. So a couple of years ago, actually in 2018, there was this great Lancet oncology paper that came out looking at kind of differences in outcomes between men and women who had immunotherapy, kind of comparing their outcomes with immunotherapy compared to historic outcomes with chemotherapy.
And that was a really kind of compelling data set. It was mostly patients that had lung cancer, non-small cell lung cancer, and melanoma. But that, of course, made me think about, well what about the patients with bladder cancer? So we partnered with Genentech, thinking about that company and all the different clinical trials that they've done with their agent Atezolizumab and really just took a look backward in time at their large randomized study, the SAUL study, as well as the original IMvigor studies. Just kind of looking at outcomes between men and women.
And what we found was this very interesting pattern in each of the studies was that the objective response rate in men tended to be higher than it was in women, and only one dataset was that difference statistically significant. And of course, this is all hypothesis generating because none of the studies were powered to look at this.
But when you kind of take that away and think about that in general practice the women in all of those studies, there was no difference in overall survival. But is there something a little bit different in terms of how the biology of women, how women are responding to the drug or maybe how their physicians are thinking about their responses. Because as we know a lot of patients might not have a wonderful response in the typical sense but are getting a great clinical benefit.
And I think that that's important and we just have to kind of remember that. So again, I think this was kind of interesting, compelling hypothesis generating work and something that I think we really need to think about as we're doing these larger phase three clinical trials moving forward.
Alicia Morgans: Absolutely. So if you had to kind of sum up your work and your interest in women in bladder and all of your urothelial cancer and give a message, both to clinicians and also to patients who might be watching, who are thinking, "This is me, she's speaking to somebody like me." What would that message be?
Jean Hoffman-Censits: Yeah, so I think the one kind of takeaway is that the continuous narrative of the delay in diagnosis and the isolation that women feel, this is not something that we think is acceptable. This is something that we recognize and that we are doing our best to change. Unfortunately, those things are happening before patients get into our clinics, but we recognize that this is an important problem in patients who get to that cancer diagnosis taking that journey really, really have a, I think special needs that need to be considered.
Being a woman and having this disease, outcomes are different. And I think until we... We're not saying that anymore, that there's work to be done and that we really need to recognize that in all of the clinical trials that we do. And not just think about the biomarkers that we're just kind of focused on, but more in general as well.
Alicia Morgans: Absolutely, so raising the bar, raising care for everybody and making sure that we meet people where they are in terms of where their needs actually stand is important. And I love that you are recognizing and elevating the needs of a population that has almost been invisible in some senses, in terms of their specific needs in the care that we deliver. So I am, I applaud your work and I really look forward to our continued conversations and seeing where things go in the future. So thank you so much for your time.
Jean Hoffman-Censits: Well, thanks for having me and thanks for letting us talk about this. Thank you.
Alicia Morgans: Hi, I'm excited to have here with me today, doctor Jean Hoffman-Censits, who is a medical oncologist at Johns Hopkins and the co-leader of the Women's Bladder Cancer Program there. Thank you so much for talking with me today.
Jean Hoffman-Censits: Well, thanks for having me.
Alicia Morgans: Of course.
Jean Hoffman-Censits: Yeah.
Alicia Morgans: So I wanted to speak with you about the Women's Bladder Cancer Program and some of the initiatives and actually some of the data that you've gathered in your research around women and bladder cancer. But can you tell me a little bit about why it's so important for you to have started a Women's Bladder Cancer Program at Hopkins?
Jean Hoffman-Censits: Sure. I think for a couple of different reasons, and we at Hopkins are passionate about this. I know this is a research and clinical interest of yours as well. When our female patients come to us, they often come to us with a very different narrative than men with bladder cancer.
Men and women both have the same presenting symptom, which is blood in their urine that is often the first sign that there's something wrong that gets them to a doctor's attention. Most men will go either straight to a urologist or maybe to a PCP and then urologist, but a lot of women take a different route and maybe they're voicing their concerns to the primary care physician, but more often than not they are treated for urinary tract infections, sent to GYN, even GI and have other procedures before ultimately seeing a urologist for a urologic complaint, blood in the urine.
In part potentially because of that, women present at a later stage with their bladder cancer, oftentimes have a worse outcome of their bladder cancer. Whether or not it's all this upfront management that's somewhat different or is it really underlying biology or combination of both, I think we're all really trying to understand that. So that's one facet that remains very fascinating, I think an unmet need for our patients is really working on that and understanding.
But the second is that process and that experience of that medical journey that a lot of women feel can be very isolating from the time that they have blood in their urine, the circuitous route to get to a urologist and then getting into that urologist office, they're often sitting in a room filled with other fellow patients who are most likely male. And then seeing a provider that's also most likely male as well. So a lot of women will come back to us in different forums and really be looking for other women who are sharing a similar experience as they're going through this journey with having a cancer diagnosis.
So I think just identifying that as a problem and an experience that we want to improve upon is important. And I think that's not only happening at Hopkins, but other centers across the country are starting to think of this as an important problem.
Alicia Morgans: Absolutely. And I think we've talked about this before, but there are some supportive care needs that women don't necessarily ask for, but really feel that they need, especially if they end up having a surgery for muscle invasive disease, like a cystectomy that leaves them with an ostomy for example. There are lots of psychological needs, some sexual needs that they need to discuss and to work through that may not always necessarily be addressed. And I love that your program really tries to address all these supportive needs around the cancer therapy itself as well.
Jean Hoffman-Censits: Yeah, absolutely. I think a lot of cancer centers have general support groups or patients with a cancer diagnosis kind of get together and have discussions and those of us that have larger bladder cancer programs, we'll have bladder-specific support groups where patients can learn from each other and at different phases along the journey, I think really come together and get the kind of knowledge and support and needs met that we really cannot do in a clinical encounter.
But one of the things that we were finding is that women felt very reluctant to speak up about really sensitive topics that only we are kind of used to talking to each other about in small groups. And so we decided not to exclude men but at the same time give women the opportunity to just talk to other women together about what does this feel like and interacting with your partner after having this procedure done or even thinking about dating after having this procedure done.
So every day we learn, I think so much from our patients and having the privilege of being a part of that support group, I think we really learn what it is that they really need and then how we as providers and people who think about these programs can make lives better for our patients kind of moving forward.
Alicia Morgans: So I know in addition to these supportive needs that you're, really addressing in your local institution, you've done some great work looking at clinical trials that have actually been completed and have thought about subgroups within the trials, thinking about trial outcomes by gender. So are there different outcomes for men versus women in completed clinical trials, where the data is accessible and you had a wonderful ESMO poster where you really kind of dug into this and I'd love to hear about that work.
Jean Hoffman-Censits: Sure. So you know, because there's never a 50/50 split in our clinical trials, there's the patients who come into our office and the incidence of bladder cancers, it's much more common in men than women. And so when you look across our large phase and you know Late-line metastatic trials, there's always 70% men and 30% women. And I think that's something that we have to kind of think about as an endpoint moving forward is thinking about potentially designing trials with a 50/50 split, at least as a secondary endpoint and kind of thinking about.
But until that day happens, we have large data sets where we can take a retrospective look. So a couple of years ago, actually in 2018, there was this great Lancet oncology paper that came out looking at kind of differences in outcomes between men and women who had immunotherapy, kind of comparing their outcomes with immunotherapy compared to historic outcomes with chemotherapy.
And that was a really kind of compelling data set. It was mostly patients that had lung cancer, non-small cell lung cancer, and melanoma. But that, of course, made me think about, well what about the patients with bladder cancer? So we partnered with Genentech, thinking about that company and all the different clinical trials that they've done with their agent Atezolizumab and really just took a look backward in time at their large randomized study, the SAUL study, as well as the original IMvigor studies. Just kind of looking at outcomes between men and women.
And what we found was this very interesting pattern in each of the studies was that the objective response rate in men tended to be higher than it was in women, and only one dataset was that difference statistically significant. And of course, this is all hypothesis generating because none of the studies were powered to look at this.
But when you kind of take that away and think about that in general practice the women in all of those studies, there was no difference in overall survival. But is there something a little bit different in terms of how the biology of women, how women are responding to the drug or maybe how their physicians are thinking about their responses. Because as we know a lot of patients might not have a wonderful response in the typical sense but are getting a great clinical benefit.
And I think that that's important and we just have to kind of remember that. So again, I think this was kind of interesting, compelling hypothesis generating work and something that I think we really need to think about as we're doing these larger phase three clinical trials moving forward.
Alicia Morgans: Absolutely. So if you had to kind of sum up your work and your interest in women in bladder and all of your urothelial cancer and give a message, both to clinicians and also to patients who might be watching, who are thinking, "This is me, she's speaking to somebody like me." What would that message be?
Jean Hoffman-Censits: Yeah, so I think the one kind of takeaway is that the continuous narrative of the delay in diagnosis and the isolation that women feel, this is not something that we think is acceptable. This is something that we recognize and that we are doing our best to change. Unfortunately, those things are happening before patients get into our clinics, but we recognize that this is an important problem in patients who get to that cancer diagnosis taking that journey really, really have a, I think special needs that need to be considered.
Being a woman and having this disease, outcomes are different. And I think until we... We're not saying that anymore, that there's work to be done and that we really need to recognize that in all of the clinical trials that we do. And not just think about the biomarkers that we're just kind of focused on, but more in general as well.
Alicia Morgans: Absolutely, so raising the bar, raising care for everybody and making sure that we meet people where they are in terms of where their needs actually stand is important. And I love that you are recognizing and elevating the needs of a population that has almost been invisible in some senses, in terms of their specific needs in the care that we deliver. So I am, I applaud your work and I really look forward to our continued conversations and seeing where things go in the future. So thank you so much for your time.
Jean Hoffman-Censits: Well, thanks for having me and thanks for letting us talk about this. Thank you.